Attachment B - EPA Form & Instructions (#8570-17)

INSTRUCTIONS
Refer to 40 CFR 172 for regulations regarding experimental use permits. These regulations were published in the FEDERAL REGISTER
on April 30, 1975 (40 FR 18780). Complete all (and only) numbered items on the applications form. If an EPA Company Number (Item 2) has not
previously been assigned, indicate “None,” and a number will be assigned on your acknowledgment copy of the form. Third party applicants (those
who will be testing another firm’s registered product) need not complete Item 13. On the acknowledgment copy of this form, you will be assigned a
File Number or Symbol for identification of this application. An expected completion date and the name of your EPA Contact will be entered. You
may call your EPA Contact if you have not received your permit or a letter of explanation by the date indicated.
Experimental Use Permit Data Submission
The following information must be submitted in triplicate and in detail (bound in removable sections A through G with margin tabs) for all
new chemicals and many new products. For some new formulations, the information requested in Items C, D, E, and F may be included by reference
to other formulations if adequate extrapolation may be made. Where the applicant requests permission to test a registered product, the information
requested in Items B, E, F, and G below, along with the EPA Registration Number of the product, will usually suffice. Refer to 40 CFR 158.640 [53
FR 15993, May 4, 1988] for further information.
A. A data sheet giving the chemical and physical properties of the chemical. A complete statement of the names and percentages by weight of each
Active and Inert Ingredient in the formulation to be shipped. This information will be handled as confidential material.
B. One copy of the proposed label including directions for use necessary for evaluation of the product. Refer to 40 CFR 172.6 for minimum
labeling requirements. In certain circumstances the experimental program or other supplemental labeling may be permissible in lieu of full
labeling. In such cases, submit a full explanation as to how the labeling will be affixed to or accompany the container.
C. Toxicity data or reference to available data on the toxicity of the pesticide including, where pertinent, date on the toxicity to fish and wildlife.
Include a summary of this information. LD 50 values and results of eye irritation studies on the formulated product must be included.
D. Residue data, where pertinent, on (a) food or feed commodities; (b) nonfood crops such as tobacco; and (c) foliage or other sites which may
relate to worker hazard or adverse effects on the environment. Include a description of the analytical method(s) used in a summary of the data.
E. Effectiveness data [required only if specified in Regulations 40 CFR 158.640, 53 FR 15993. May 4, 1988 and Registration Guidelines 40 CFR
158.202(i), 53 FR 15993, May 4, 1988].
F. If the pesticide is to be tested in a manner involving food or feed, and an adequate tolerance is not established to cover the use, file a petition for
a temporary tolerance with this Agency and forward three copies with this application. If appropriate tolerances are established already, cite
applicable Regulation in Title 40 of the Code of Federal Regulations.
G. Proposed Experimental Program:
(1) Give the qualifications and the names, addresses, and telephone numbers of the individuals (participants) who will supervise the
experimental work.
(2) Name the States in which the pesticide will be used and the acreage to be treated in each State. Where “acreage” does not apply, give
extent of testing per State in more appropriate terminology. Indicate separately any other State(s) to which the pesticide may be shipped for
further distribution.
(3) Give the details of the proposed program including the types of target pests and organisms, the crops, animals, surfaces, materials,
buildings, or sites of application to be treated and the major geographical areas where the material is to be used. For seasonal pests or crops,
indicate the desired month for pesticide application to begin. Specify the use pattern, intended plot sizes, number of plots, number of
replicates, dosage rates, methods of application, season of use (spring, summer, fall) and timing of application (preplant, postemergence,
multiple (indicate pattern and number), etc.).
(4) List the objectives of the proposed program including, e.g., what types of data will be collected during the testing period (performance,
yield, phytotoxicity. environmental residue, etc.). Indicate your long-range testing plans, including how many years you expect to conduct
experimental testing in support of registration of this use. This information will be helpful in evaluating the currently proposed program.
(5) Submit an explanation to justify the quantity of the material requested, including various parameters used to determine the quantity.
Quantities authorized will be based on the program submitted and consideration of the types and amount of data required to support
registration.
(6) Propose a suitable duration for the permit commensurate with the program. Any request for a period greater than 1 year must be
adequately justified.
(7) State the method of disposition of any unused materials left at the conclusion of the testing program.
Paperw ork Reduction Act Notice
The public reporting burden for this collection of information is estimated to average 0.75 hours including time for reviewing instructions,
gathering existing product sources and addresses, shippers to be used and addresses, and completing this instrument. Send comments regarding this
estimate or any other aspect of this process, including suggestions for reducing burden to : Director, Collection Strategies Division, 1200
Pennsylvania Avenue, N.W., Washington, DC 20460; Office of Management and Budget. Paperwork Reduction Act Project (2070-0040),
Washington, DC 20503, marked “Attention: Desk Officer for EPA.”
NOTE: Applicant may retain last copy
(11-24-2003)